Professional Reimbursement by Medicaid for Cochlear Implants and Related Services

Medicaid reimbursement rates for cochlear implants and related services fall short of the federal benchmark set by Medicare.

The financial hardships of cochlear implant centers around the United States may be a repercussion of poor Medicaid reimbursement. In time, these reimbursement discrepancies could force additional Otolaryngologists and cochlear implant centers to not provide these crucial services due to financial limitations.

Based on Medicare (MCR) claims data, current procedural terminology (CPT) codes used for cochlear implantation and related services were selected. Medicaid (MCD) and Medicare (MCR) payment schemes were queried for the same services in 49 states and Washington, D.C. The difference in MCD and MCR payment in dollars and percent was determined and reimbursement per relative value of work (RVU) calculated. MCD reimbursement differences (by dollar amount and by percentage) were qualified as a shortfall or excess as compared with the MCR benchmark.

Marked differences in MCD and MCR reimbursement exist for all cochlear implant related services, most commonly as a substantial shortfall. The MCD shortfall varied in amount between states and great variability in reimbursement exists within and between audiology, surgery, and speech services. Shortfalls and excesses were not consistent between procedures or states.

The variation in MCD payment models reflects marked differences in the value of the same work provided, which in many cases is far less than federal benchmarks. These results question the fairness of the MCD reimbursement scheme in cochlear implantation with potential serious implications on access to care for this underserved patient population.